Provider Demographics
NPI:1669954202
Name:TREVINO, TEODORO
Entity type:Individual
Prefix:
First Name:TEODORO
Middle Name:
Last Name:TREVINO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8210 N JASMAN RD
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78542-4334
Mailing Address - Country:US
Mailing Address - Phone:956-393-0105
Mailing Address - Fax:
Practice Address - Street 1:1313 E JASMINE AVE
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78501-5785
Practice Address - Country:US
Practice Address - Phone:956-627-0554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2016853225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant